Join me as I summarise Mona Ghoussoub’s lecture looking at the excessive gingival display (EGD).
Mona looked at the diagnosis and treatment of EGD, with a focus on aetiology leading to treatment method, effect of age, and input of multidisciplinary care for appropriate cases.
Definition Kokich 1999, Machado 2014
- Negative effects = 4mm + gingival display
Diagnosis identifying aetilogy
- Medical history – medication
- Facial analysis – VME
- Lip analysis –
- short lip: lip length 20-22mm
- hypermobility of elevator muscles
- Lip line
- Age increases = greater increase in mandibular incisor show, after 40 years of age, great mandibular incisor show then maxillary incisor show
- Location, anterior or posterior increase
- Dental analysis – Short crowns = crown height
- Maxillary incisor width : height = 80%
- Centreline Coincident = well intercuspation
- Periodontal examination
- Altered passive eruption
- Pocket without pathology
- Altered passive eruption
Treatment approach
Early treatment
- Medical ENT allergology
- Excessive gingival show age 7-8 years
- Nasal obstruction causes decrease in lip closing force Sabashi 2011
- Detect and refer ENT if suspect nasal obstruction
- Dark eyes
- Flat cheeks
- Increase LAFH
- Orthodontic – prevention
- Utility arch
- Intrusion upper anterior teeth
- 4 brackets and molar bands
- Retain with 2 layers of Essix + brass wire – for rigidity
- Utility arch
Late treatment
- Orthodontic
- Alignment
- 2 occlusal planes in maxilla in 2 div 2, posterior higher, anterior lower
- Straight wire – reciprocal effects
- Intrusion of anterior teeth
- Extrusion of posterior teeth
- Expansion
- RME
- Posterior expansion = gingival position moves upwards
- When constricted, greater posterior gingival show
- Posterior expansion = gingival position moves upwards
- RME
- Straight wire – reciprocal effects
- 2 occlusal planes in maxilla in 2 div 2, posterior higher, anterior lower
- Alignment
- Intrusion
- Ricketts / Burstone 3 piece intrusion arch
- Headgear – J hook intrude upper anterior teeth
- TAD placement for anterior intrusion
- UR1-UL1 labial
- Powerchain archwire to TAD
- TAD for posterior intrusion
- U5-U6 region buccal
- Direct retraction U3- TAD
- Below centre of rotation = posterior intrusion
- MDT
- Periodontics
- Gingivectomy – passive over-eruption of dentition
- Ideal where tooth width:height ratio increased
- Guided Tissue Regeneration for VME
- Stable after 1 year
- 40-60% improvement in excessive gingival growth, with crown lengthening
- Bony cavity at anterior superior aspect of maxilla
- Results in the lip raising higher
- Bone augmented at the level of the Le-fort 1
- Can be clinically simulated with cotton wool rolls in upper labial sulcus and taking photos
- Orthognathic surgery
- Decompensate
- Maxillary impaction
- Plastic surgery Pierre 2020
- Short lip / mild VME = lip repositioning surgery Rubinstein 1973
- Limit the smile muscle pull by reducing the depth of the upper vestibule– zygomaticus minor, levator Angulo, orbicularis oris, levator labil superior Tawfik 2018
- Conservative when compared to OGN
- Technique
- Split thickness flap – expose connective tissue
- Advance mucosa and suture at mucogingival junction
- Limited studies
- Overcorrect as some relapse expected
- Systematic review improve EGD 3-4mm Tawfik 2018
- Hypermobile lip – Botox Cengiz 2020
- Reduce muscle activity – levator labil superios LLSAN, zygomaticus minor / major, risorius muscle
- NOT classified as an alternate treatment for EGD
- Use = indication for patient outcomes possible for lip reposition
- Temporary effects – relapse at 6 months
- Problems
- Dose related results
- Excessive upper lip ptorsis
- Too little – not achieve desired result
- Smile effected if erroneous
- = require expert to use
- Short lip / mild VME = lip repositioning surgery Rubinstein 1973
- Decompensate
- Gingivectomy – passive over-eruption of dentition
- Periodontics
Conclusion
- Not all patients are the same
- Age / skeletal / gingival aetiology
- Explore differential diagnosis
- Treatment outcome – inter-incisal angle for stability for intrusion
- Overcorrect intrusion
- Individualise retention
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